Hospitalization Record

Name: Edwin Sanchez                        Gender: Male

Age: 36 years old                               Nationality: United States of America

Profession: Construction                      Height: 5.7                                            

Weight:168 lbs.

Time of Hospitalization: April 13, 2005. 10:Am

 

Major complaint: Inward stomach pressure for three months, much gas accumulation inside the stomach which causes big discomfort. Slight burning inside, radiating slight pains to the back.

No obvious reason to cause current health problem, maybe due to slight emotional stress. One year ago, the patient felt slight stomach pressure and was given intravenous injection to relax the stomach muscle, the condition was gone. About three months ago, Mr. Edwin felt inward stomach pressure happening again. In recent five weeks, the local distention is persistent, with intermittent burning sense. No obvious pains locally. Lots of gas inside, many times of gas passing everyday, especially after meal. Also there is a feature, after food intake, the distention can be relieved. Yet, after the meal, much more gas is produced. This can cause the back radiating pains worsened. Both too cold and too hot drinks could worsen the feeling. No vomiting sense. Sometimes there is acid regurgitation in a little way. Not mucus or saliva increase in the mouth. The appetite is reduced and the food intake is reduced about thirty percent. The discomfort area is the upper middle abdomen. Sometimes the local part is pulsating.

No loss of hair, no tinnitus. The eyes are sometimes dry when waking up. No blockade or runny nose. No obvious dry lips or mouth, but during recent four weeks, he is not thirsty but forced himself to drink a lot. No obvious bitter taste, salty taste in the mouth. When he is very worrisome he feels the throat is hard to swallow foods. No chest pains or distention, no palpitations.

In general, the middle and the lower abdomen are comfortable without any distention or pains. The bowel movement is once or twice a day, neither sloppy nor diarrhea. The urine is sometimes yellowish, no frequent urination, no night urination when sleeping. No prostate and no man’s problems. The legs are strong.

In the past, the emotional state is quite peaceful, so the sleep, spirit and appetite are quite normal. During recent weeks, the emotional state is melancholic, depressed and worrisome. The sleep is unrest and easy to wake up, and even shaking of the body happens sometimes. The spirit is reduced 30%. Ten pounds were lost recently.

No sweat in the daytime and at night. No aversion to cold. No hot sense in the palms and in the soles in the afternoon. The back is generally comfortable except this radiating pains from stomach.

The patient made an operation in 1997 for herniated disk, cervical vertebra No.7. No other history of diseases. The New York hospital check by biopsy and stomach camera reveals that there is a major ulcer at the lower part of the stomach and three small ulcers. All other check range normally. No coughing, no phlegm spitting. No swelling of the body.

The tongue is moist. There is much fluids inside the mouth. The tongue coating is greasy and yellowish. The pulse is string-like with slightly slippery.

Current Diagnosis: Western medicine: gastric ulcer

TCM: liver qi stagnation, damp heat in the stomach.

Treatment strategy: smoothing the liver qi, moving the qi, tonifying the spleen, restraining acid, clearing heat, reducing dampness.

bupleurum root 12g, curcuma tuber 10g, codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g,  amommon 10g, sausurea root 10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g,  blettilla  12g, wild chrysanthemum root 15g, dandelion 15g.

                                                                                      
First two dosages for two days supply. Taking 150 to 200 milliliters each time and twice a day.

April 13, yesterday 2:00 pm, taking the first tea for 150 milliliters, no abnormal feeling. 6:00 pm for the second dosage of tea for 200 milliliters. The stomach could accept. One hour later, more intensive inward pressure could be felt. Twenty percent increase of burning sense inside the stomach. 9:00, taking very little dinner, both the burning sense and inward pressure were not relieved. Even felt the dropping sense of the stomach.

In the recent weeks, every two days, the patient could feel the radiating pains to the back from due to the stomach problem, lasting two hours each time. This feeling almost could not be felt yesterday.

No vomiting sense, no diarrhea. This morning the appetite return 50% compared to the condition at home in the normal situation.

No bitter taste in the mouth, no sour taste in the mouth. The gas accumulates in the stomach is reduced fifteen percent.

In the past, at home, when taking the meal, the patient may fell very tired and sleepy and weak for half an hour. This feeling does not happen yesterday and today. 

At home, after eating the stomach pressure is reduced 80% to 90%. This breakfast makes the pressure reduced 60%

astragalus root 20g,  cimicifuge 10g, bupleurum root 12g, curcuma tuber10g, codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g,   amommon 10g, sausurea 10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone　12g, blettilla 12g, wild chrysanthemum root 15g, dandelion 15g.

This dosage is for April 15. Putting astragalus root 20g and cimicifuge 10g to lift the middle qi.

April 15, 2005. Yesterday, as to the lunch and dinner, Edwin was returning to normal appetite, feeling hungry.

Last night, the sleeping is quite calm from 9:00 Pm to 3:00 Am this morning. The bowl movement is normal at 3:00 Am. 9:00 Pm last night, much gas inside the abdomen, relieved after the bowl movement.

This morning, good appetite. Now, the patient is feeling that the inward pressure is reduced thirty percent. Compared to the same time in America, the gas accumulation in the stomach is reduced fifty percent. No acid or bitter taste in the mouth. No radiating pains to the back. No dropping sense of stomach..

The urine is less yellowish. The tongue coating is less yellowish and thinner. The liver pulse is less string-like a little bit.

cimicifuge 10g, bupleurum root 12g, curcuma tuber 10g, codonopsis root 15g, ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g,  amommon 10g, sausurea　10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g, blettilla 12g,               wild chrysanthemum root 15g, dandelion 15g.  One dosage.

Since the dropping sense is not too much, so removing astragalus root 20g. The other ingredients keep the same.

                                                                                            Dr. Ming

April 16, 2005, yesterday the patient took a very little walk across the street, started getting pressure 2:20 Pm. Drank the tea at 3:45 Pm, one hour latter, great pressure and much gas and great radiating pains at the back. Laid down about 5:45 to 6:05, the gas and distention and pains relieved 10%. After about three hours, the distention, pains and much gas were gone. But no burning sense in the stomach.

The appetite is good for dinner. Sleep is calm from ten Pm to 5:30 Am this morning. So now, the stomach feels comfortable, no gas inside, no radiating pain, no burning sense. This breakfast, the patient has good appetite. The tongue is still slightly yellowish.

To remove the herbs astragalus root and cimicifuge, the first step is to heal the ulcer. Add areca 10g inside the formula to strengthen moving the qi.

bupleurum root 12g, curcuma tuber10g, areca husk 10g, codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g, blettilla　12g, wild chrysanthemum root 15g,  dandelion 15g.


                                                                                       Dr. Ming

April 17,2005. So the general condition of Edwin is the ulcer of stomach. And due to over-worriment of his condition, this causes drooping down of the stomach qi. So once he walks or stand for about 20 minutes, he feels much gas inside the stomach, radiating pains to the back and inward pressure of the stomach.

Yesterday the appetite is good. From 12:00 to 2:00 pm, the patient feels much gas inside the abdomen, radiating pains to the back and inward pressure. After 2:00, all the symptoms almost relieved without abnormal feeling.

This morning, good breakfast. Right now, no any abnormal sense. The tongue coating is less yellowish. The bowl movement is easy to defecate.

Put scutellaria 8g in the former formula for another day to help clear the heat.

April 18, 2005, yesterday, the major abnormal feeling is the back muscle pains at the superficial area. Almost no stomach inward pressure, no gas accumulation the whole day. This morning, good appetite for breakfast. Middle degree back pains of muscles. The patient self feels that the inward pressure is 70% reduced. The gas accumulation is 65% reduced. No stomach burning sense, no acid regurgitation. The stool is little bit constipated. So put two herbal ingredients to moisten the intestines to help deification.

bupleurum root 12g, curcuma tuber 10g, hemp seed 10 g, codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g, blettilla　12g, wild chrysanthemum root 15g, dandelion 15g, bushy cherry 10g, scutellaria root  10g.

                                                                           
                                                                                       Dr. Ming

April 19, 2005, yesterday in the morning, the patient did not feel some abnormal feeling about the stomach, such as inward pressure of the stomach, gas accumulation, only the back muscle pains. After the message for 20 minutes, the pains were reduced 80%. Considering this tender point beside the vertebra is the muscle strain or due to hard labor which damaged the old wound, since 8 years old there was a surgical operation for this part of vertebra.

So our conclusion that Edwin suffers three condition, stomach ulcer, stomach qi dropping down, and old wound damage of the back. The sleep of last night is calm.

This morning, the patient does not feel discomfort of the stomach, such as stomach pressure, dropping sense, burning sense and gas accumulation.

Now, if moving the arms left and right, mild pains at the former tender point. If do not move the arms left and right, no pains.

The spirit is energetic. The complexion looks better. The tongue coating is less yellowish.

bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g, codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g,  poria 10g, amommon 10g,
sausurea 10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g, blettilla　12g, wild chrysanthemum root 15g, dandelion 15g, bushy cherry 10g.


                                                                                        Dr. Ming
　

April 20, 2005, yesterday only 3:00 to 7:00, there is 30% inward pressure of stomach, and 20% gas accumulation inside the stomach. No back pains. Good sleep last night. The stool is normal.

This morning, every symptom does not exist. The patient feels very good. The tongue coating is slightly yellowish.

bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g, codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g,  poria 10g, amommon 10g,
sausurea 10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g, blettilla　12g, wild chrysanthemum root 15g, dandelion 15g, bushy cherry 10g, areca husk  10g.

                                                                                         Dr. Zhu Ming

April 21, 2005, yesterday the stomach generally feels good, no inward pressure of the stomach, only twenty percent gas accumulation. Back pains medium degree for three hours. Appetite is good, bowl movement is normal. Today, the stomach is fine. Much gurgling sound in the abdomen, no distention, so it is good movement of the intestines.

bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g, codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g, amommon 10g,
sausurea 10g, cyperus root 10g, bitter orange 10g, cuttle-fish bone 12g, blettilla　12g, wild chrysanthemum root 15g, dandelion 15g, bushy cherry 10g, areca husk  10g.


                                                                                         Dr. Zhu Ming

April 22, 2005, yesterday, the stomach generally feels fine and comfortable. There are two hours slight gas accumulation. This morning, good appetite. There is no inward stomach pressure and gas accumulation. The local massage on the back helps the tender pains a lot.

So Edwin stays in our hospital for herb tea treatment for ten days. The clinical symptoms and suffering were relieved eighty percent, he said.

So the final diagnosis for Edwin is gastric ulcer, spleen qi dropping down, and old wound damage on the back.

Now, tomorrow Edwin will leave Huaihua. We suggest Edwin taking 40 days dosage back home to continue with the treatment so that full recovery could be gained soon.

Please be careful with spicy foods, alcohol, beer and drinks like Coca-Cola. Keep emotionally relaxed and happy. Avoid taking up heavy articles. Massage the back for a period to relieve the muscle strains.

bupleurum root 12g, curcuma tuber 10g, scutellaria root 10g, codonopsis root 15g,
ovate atractylodes rhizome 15g, Chinese yam 10g, poria 10g, amommon 10g, sausurea 10g, cyperus root 10g, bitter orange 15g, cuttle-fish bone 12g, blettilla　12g, wild chrysanthemum root 15g, dandelion 15g, bushy cherry 10g, turmeric  10g, peach kernel  10g.
                            


                                                                                         Dr. Zhu Ming

Another case of gastritis we treat well here.